Healthcare Provider Details

I. General information

NPI: 1053835496
Provider Name (Legal Business Name): CHILD AND ADOLESCENT BEHAVIORAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17772 IRVINE BLVD STE 103
TUSTIN CA
92780
US

IV. Provider business mailing address

17772 IRVINE BLVD STE 103
TUSTIN CA
92780-3256
US

V. Phone/Fax

Practice location:
  • Phone: 714-696-1385
  • Fax: 888-972-4028
Mailing address:
  • Phone: 714-696-1385
  • Fax: 888-972-4028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. IRIS A RICHARDSON
Title or Position: PARTNER
Credential: PH.D.
Phone: 714-696-1385